California Institute for Mental Health
Page 1
IMPLEMENTING EVIDENCE-BASED PRACTICES
Transition to Independence Process (TIP) Model
Description of the practice
Target group and mission: Persons age 14-25 who have emotional or behavioral difficulties. This term is
used to “encompass a variety of diagnoses and classifications that are applied differently in different
child- and adult-serving systems and states (e.g. Severe Emotional Disturbance [SED], childhood chronic
depression, emotionally handicapped [EH], and severe mental illness.)” The target group criteria for the
TIP may thus be more inclusive than those applied in most county mental health systems, which focus
only on those defined (by various legal entities) as meeting SED or Serious mental illness (SMI) criteria.
The mission is to assist young persons in making a successful transition into adulthood, so that they
achieve personal goals in the transition domains of employment, education, living situation, personal
adjustment, and community life functioning.
Practice components: TIP comprises both a set of principles, or “guidelines,” and an organizational
structure.
GUIDELINES: 1

Engage young people through relationship development, person-centered planning, and a focus
on their futures.

Tailor services and supports to be accessible, coordinated, developmentally-appropriate, and
build on strengths to enable the young people to pursue their goals across all transition domains.

Acknowledge and develop personal choice and social responsibility with young people.

Ensure a safety-net of support by involving a young person’s parents, family members, and other
informal and formal key players.

Enhance young persons’ competencies to assist them in achieving greater self- sufficiency and
confidence.

Maintain an outcome focus in the TIP system at the young person, program, and community
levels.

Involve young people, parents, and other community partners in the TIP system at the practice,
program, and community levels.
California Institute for Mental Health
Page 2
ORGANIZATIONAL STRUCTURE AND FUNCTIONS:
The primary means for accomplishing the guidelines is a team of “transition facilitators.” Facilitators
perform a wide range of functions, the most critical of which appears to be:

Conduct strength-based assessments and facilitate person-centered planning, including crisis
prevention

Assist the youth and young adults in setting and achieving their goals across the transition
domains

Coach and teach these young people as they progress through service stages

Work collaboratively with mental health staff, welfare staff, teachers, rehabilitation
specialists, and others in order to ensure appropriate services

Promote the involvement of parents and additional informal and formal key players – and
assist the young people in the development of a healthy supportive social support network.

Make appropriate referrals for clinical, medical or other services

Work with young people in community settings that are comfortable and non-stigmatizing, at
times that are convenient for them

There is to be a Community Steering Committee which functions either as a governing board
or advisory committee. It is made up of representatives of a wide range of child- and adultserving agencies relevant to the transition process; and also including advocates, parents, and
young people.
There is to be a Community Steering Committee which functions either as a governing board or advisory
committee. It is made up of representatives of a wide range of agencies relevant to the transition process,
including advocates and work-force development organizations.
There must be extensive resource development through the transition facilitators and their supervisor, as
many of the resources and links necessary for success will not exist (e.g., community college, housing,
job development).
The services are organized temporally in this way:
1. Initial Assessment and Planning to be completed within 7 to 45 days of assignment to the
TIP team
2. Active Coaching Status lasts on average 8 months with a typical range from 3 to 15
months
3. Maintenance Coaching Status lasts on average 18 months with range from 4 to 48 months
4. Follow-along Status to maintain community services/supports
Caseload: A transition facilitator can usually serve a maximum of 15 young people, with one third being
in each of the status categories (i.e., active coaching, maintenance coaching, follow-along) as described
California Institute for Mental Health
Page 3
previously. Most sites have transition facilitators serving 8 to 15 young people at a time.
Also, there is a supervisor for the transition facilitators who is responsible for recruiting and training
transition facilitators, weekly supervision sessions with the transition facilitators, development of
resources, monitoring of progress and outcomes, and overall management of the project.
Almost all of the TIP sites assign the young people to transition facilitators in the traditional case
management style where each facilitator has responsibility for specific clients. A few sites have tried, or
are using, more of an ACT team caseload assignment in which responsibility for each client is shared by
the whole team.
Extent of evidence
A.
Studies of programs that have been identified with the TIP model. There are three empirical
studies of programs that were intended to embody most or all of the TIP guidelines and associated
practices. In addition, there is a five-site “Partnerships for Youth Transition” study underway:
preliminary results from a Washington Partnerships for Youth Transition site are currently
available as are preliminary results aggregated for all sites.
1.
The “Steps to Success” Program.2 The Steps to Success (STS) program was one of the
early TIP program adopters. Sixty-eight students exited the program during the period
from 1997-2002. Of the 68 leaving the program, 43 had at least one year of exposure to
the program. This STS group was compared, by the TIP developers, on several outcome
measures with a matched comparison group of students in the Miami-Dade schools
having an emotional-behavioral disturbance (EBD) classification in 1997 and with a
matched comparison group of students with no disability classifications (called
“Typical”). All participants were from this same geographical area of Miami, Florida.
Matching was done on gender, ethnicity/race, and age. The findings showed STS exiters
to have a non-statistically significant lower rate of employment than the EBD control
group. (The proportion of Typical young adults employed was higher than in either of
these groups.) The post-secondary education involvement by the STS exiters approached
the norm reference set by the Typical young adults, and was statistically significantly
higher than that of the EBD matched comparison group. The STS exiters had
significantly fewer incarcerations than did the EBD comparison group. Although the
Steps to Success group did better than the EBD group on two of the three measures, there
are two serious methodological problems that weaken the conclusion that the Steps-toSuccess intervention was responsible. First, there are significant issues of selection bias.
A) 11 persons were excluded from the experimental group because of disciplinary
problems (but young people with disciplinary issues were eligible to be drawn from the
EBD population for inclusion in the matched EBD comparison group). B) There was selfselection into the STS program (by students themselves and their IEP committees) rather
than random assignment. C) Although participants were matched on age, sex, and
race/ethnicity, this is not comparable to random assignment as a way of eliminating
potential bias. D) It was not possible to control for “pre” status (such as high school
graduation or earlier incarcerations). A second major problem is that the Steps-toSuccess program does not appear to reflect the model in critical ways: for example, no
funding was ever obtained for ”official” transition facilitators. Instead services appear to
be an ad hoc mix of planning, vocational preparation, treatment, and education carried
out by existing personnel assuming the role of “transition facilitators.”
California Institute for Mental Health
Page 4
2.
Jump on Board for Success (JOBS).3 The JOBS program is an implementation of the TIP
model in several sites in Vermont. The initial site is in Washington County, VT. The
JOBS program there dates back to the early 90s. Participants are SED and are eligible for
admission through age 20 and can receive services through age 22. The program is a
collaboration of education, corrections, vocational rehabilitation and mental health
agencies. There is a transition specialist with functions as described above. Preliminary
outcomes [not reported] resulted in expansion of the model to eight other sites, with the
Department of Vocational Rehabilitation having a lead role supported by Corrections,
Mental Health, and Child Welfare. A pre-post evaluation was performed for 80
participants. The 80 were graduates of three sites over 7 years, 94-2001. They averaged
almost 18 when entering (range 16-20) and received an average of 7.6 hours of service a
month. Like Vermont overall, 97% were white; two thirds were males. Study group
members had to meet DVR requirements for successful closure, that is, to have been
employed 90 days. The 80 participants showed positive pre-post increases in employment
and high school graduation or obtaining a GED; there were decreases in homelessness,
residential treatment, intensive mental health treatment, welfare support, and corrections
involvement. Only a narrow age range (young adult) is represented in the study group,
limiting external validity (as does the atypical ethnic composition). Like the previous
study there are also very serious methodological problems. A) There was no control
group. B) There was an equal number of participants who did not achieve successful
DVR closure, but data are presented only for those who did. C) There was no control on
what other services (such as case management or mental health treatments) participants
might have received.
3.
Partnerships for Youth Transition programs.
The OPTIONS program in Clark County, Washington4 is the only Partnerships for
Youth Transition site to have reported detailed preliminary findings. Options has
transition specialists, a job-developer, and a supervisor for a population of 47 at any one
time. Participants are in (or at risk of) out of home placement and have a DSM IV
diagnosis. Two-thirds had been in special education and 75% had been arrested prior to
admission. Clients are 14-21 at time of intake but can stay until age 25 if necessary. A
modified TIP fidelity process is used. Outcome data through 9 months of service are
available for 51 participants regarding living situation, employment, education, criminal
justice contacts. Participants received an average of 99 hours of service each. At 9
months, about half of the youth (46%) showed consistently positive outcomes in all four
or three domains and 31% of the youth showed negative outcomes in three or four
domains. Education showed the most consistent gains with a decrease in arrest showing
the largest improvement. These results, though modestly positive, also have serious
methodological problems: A) There is no control group; and B) data are limited to
persons who completed nine months of services (we don’t know about drop outs). C)
Although participants had very serious histories, there may be a selection effect (persons
with more promise chose to be in the program), so that results might not be replicated
with a broad population.
The other Partnerships for Youth Transition programs have begun reporting preliminary
outcomes. Although detailed results are not yet available the, developers have described
preliminary overall findings for the 194 persons who were enrolled in a PYT program for
at least one year. In general, there were positive trends for involvement in employment,
or school, and a reduction in school dropouts. There was a trend toward less interference
with functioning by mental health and by substance abuse problems. Arrests were low
California Institute for Mental Health
Page 5
and did not change significantly. Although the TIP developers are consultants to and
evaluators of the Partnerships in Transition programs, the degree of fidelity to the TIP
model varies considerably. The evaluator of one program told us they do not use TIP at
all; however, the data are not yet disaggregated by service model. The data system is one
that is required by SAMHSA, and it is limited in what it can report uniformly; attrition,
for example, is not reported uniformly. None of the programs have a control group. Thus
the PYT program evaluations share the major methodological problems of the other
studies: lack of clarity in the model, lack of attrition information, and lack of a control
group or even solid “pre” information.
B.
Studies of programs which embody a number of the TIP guidelines
1.
Project ARIES in Springfield, Oregon.5 Oregon has a long-established transition program
based on interagency collaboration, but this was the first implementation to focus on
youth with emotional problems. Project Aries was administered through the education
system, but had a separate house as a center and very experienced teachers with masters’
degrees as transition specialists. Caseloads were in the range of 10-15, and a number of
the TIP guidelines were observed, such as person-centered planning and individualized
services. Initially there was a focus on competitive employment, but it changed to a focus
on completing educational programs. There were 85 participants, with 61 formally
existing the program. Of the latter, 61% obtained some sort of educational degree or
certificate and about half planned to go on to get more schooling or training. Some sort of
paid work was performed during services by 55% of those exiting formally, and 36%
were working at exit. Information about the program and participants is quite limited.
Clear methodological problems include: A) Lack of a control group; B) Lack of baseline
information on employment and schooling; C) and lack of information about the 25%
who did not formally exit the program.
2.
Project RENEW (Rehabilitation, Empowerment, Natural Supports, Education, and Work)
in New Hampshire.6 This was a small project starting in 1995 and based in a junior
college. Staff were career and education specialists. There was strong interagency
collaboration and a mentoring component as well as personal futures planning and
flexible education services. Other components include skill building and flexible funds.
We learn the outcomes of 18 participants (age 16-20) who stayed in services two years,
but do not learn whether there were others who dropped out. At baseline: seven (39%)
had already completed high school or obtained a general equivalency diploma (GED),
and 2 participants (11%) were engaged in paid employment. Thirteen participants (72%)
had had police or court involvement in the past 3 months. After two years only 17% had
recent criminal justice contact, 17 of 18 had completed secondary school or were still in
school, and 11 of 18 (61%) were employed. (In the two years 83% had been employed at
some point.) Methodological problems include: A) Lack of a comparison group, B) little
information on recruitment, C) no information on drop outs.
3.
Job Designs7 was an Oregon employment-focused transition program situated on the
campus of a residential mental health treatment program. The program lasted for ten
years, starting in 1989, and limited evaluation data are available for the 1992-1995
period. The area is largely rural and the clients mostly white. Clients had a variety of
behavioral problems and about a third were eligible for SED services. Outcome data were
collected for 79 persons during this period. Some competitive work was recorded for 56
persons (71%) during the study period. (Earlier data show 39% of those working to be
“successful” and 61% to be “unsuccessful.”) During the study period 53 persons left the
California Institute for Mental Health
Page 6
program, but the reasons for leaving are not clearly defined. Of the 53 persons leaving,
21% had dropped out of school, 30% had finished high school and 49% had attended
school during their tenure in the Job Designs program. An exit interview was conducted
with 36 clients; of these 24 (67%) said they would recommend Job Designs to a friend.
The typical client received services from three or four agencies. The actual Job Designs
program included a supervisor and three transition facilitators with caseloads of 1/15 or
lower. The success rate is very low (39% of the 71% who worked were successful, or
28%). The rate of consumer satisfaction is very low compared to most mental health
programs, where 85% or more typically would recommend a program to a friend. There
was no control group, no pre vs. post measures, and no follow-up once participants left
the program.
C.
D.
Systematic Reviews of TIP Model Research
1.
There are no reviews of TIP model studies, per se. A recent general review of the issues
of transition to adulthood for persons with SED is provided by Davis.8 She cites several
research efforts but concludes, “…None of the studies have employed an appropriate
control or comparison group, so the findings should be viewed with caution.”
2.
A comprehensive review of policy and research relevant to youth aging out of foster care
was done by Collins.9 The empirical results reviewed are studies of the federal
Independent Living Program.
3.
A CIMH publication written by Lynne Marsenich reviews the literature on clinical needs
and treatment of transition age young women.10 Many psychiatric disorders (eating
disorders, PTSD) are much more likely to be experienced by young women, and services
need to be specialized for them; for example, young mothers need special supports. The
report includes important suggestions for how to provide transition services but does not
review the transition services empirical literature.
Adaptations for culture and other sub-populations
TIP guidelines stress cultural competence. However, although youth of multiple races and
cultures have been part of some of the research regarding TIP, more of the studies have been in
New England or other places with limited diversity. No adaptations for other cultures (regarding,
say, the role of the family) have been reported. As noted above, gender has significant effects on
transition needs, but the TIP studies reported here have not focused on gender differences nor
does the TIP model. The model (and studies of the model) also do not clearly distinguish
subgroups by clinical status (e.g., conduct disorders vs. SMI vs. anxiety disorders such as PTSD).
Capsule Summary of Evidence: Effective, Efficacious, Promising, or Emerging, Not
effective or Harmful.
Because of the numerous methodological problems cited in exiting studies, the empirical support for the
TIP model to date is weak. The model has, however, a strong theoretical base and fairly well-developed
tools for implementation and is continuing to build a research base. It is rated as an promising evidencebased practice since it has some empirical support.
Clearly there is a critical need for studies to examine transition practices and systems for improving the
progress and outcomes of youth and young adults with emotional and behavioral difficulties. In order to
be a strong evidence-based practice, several randomized controlled trials will be necessary. Unlike ACT,
California Institute for Mental Health
Page 7
for example, which has one specialized function (reducing hospital days) for a clearly defined population
(high hospital utilizers), TIP takes aim at a very wide range of systems, problems, and populations. In
order to test the model adequately, trials are needed with a) different age groups (14 year olds have little
in common with 24 year olds) b) different types and severity of disorder (behavior problems in school are
quite different from schizophrenia spectrum disorders), c) different lead agencies and funding sources
(services are likely to be different if located in schools as opposed to probation or mental health agencies,
in part because of the requirements of categorical funding sources), and d) different institutional sources
of clients (corrections, special education, residential treatment, foster care). Since TIP is based on broadly
applicable principles it may well be effective in all these situations, but the very diversity of transition
challenges necessitates an equal diversity in empirical trials.
Information about the implementation process
1.
Fidelity Scale
The approach to fidelity we have attempted to use in these summaries is stated in a manual on
EBP sponsored by the American College of Mental Health Administration11:
Fidelity is adherence to the key elements of an evidence-based
practice, as described in the controlled experimental design, and
that are shown to be critical to achieving the positive results
found in a controlled trial.
The three steps in developing a fidelity scale then are a) determining a program model or practice
is effective (preferably through randomized controlled trials) and b) determining what
components of the program are associated with the effective outcomes, and c) measuring the
effective elements with a scale that, when scored high, indicates (based on further empirical
trials) that the effective outcomes in the randomized research will be replicated in the field.
Since TIP does not yet have any controlled studies, “fidelity” here is limited to adherence to an a
not yet validated set of program guidelines. Such guidelines are useful in ensuring model
implementation but—lacking correlation with rigorous outcome research—high fidelity will not
necessarily ensure good outcomes.
In a personal communication the developers write: “We have developed, pilot-tested, and are
refining a protocol for TIP Program Fidelity. We will be applying the new version to three or four
of the [PYT] sites.” In addition, materials on the developers’ website offer information on an
previous version of a TIP system improvement tool. “The TIP Case Study Protocol for
Continuing System Improvement can be used to assist stakeholders in establishing a profile of the
system's areas of strengths and weaknesses. This protocol uses multiple sources of information
(e.g., the young person, a family member, a teacher, the transition facilitator, a service provider
and record review) to document various components of the transition process (e.g., strengths,
needs, transition planning, coordination, supports and services provided, gaps in support/service
provision, effectiveness, and satisfaction) in a particular environment (e.g., school, school district,
community). The information provided through the TIP Case Study analysis can be used by the
administrators, staff, and other interested stakeholders to recognize the strengths of the TIP
system and to set the occasion for their making modifications to further enhance the service
system.”
California Institute for Mental Health
2.
Page 8
Implementation assistance available
a.
Manual or other detailed description by developers. There is an “TIP Operations
Manual”12 and training modules are available.
b.
Developers available to assist. Competency-based training and training-of-trainer
workshops can be arranged to strengthen an organization’s transition program capacity
with Hewitt B. "Rusty" Clark, Ph.D., Nicole DeschÍnes, M.Ed., Jordan Knab, Ed.S., Arun
Karpur, M.PH, or Mason Haber, Ph.D. of the National Center on Youth Transition for
Behavioral Health: System Development & Research Team, Florida Mental Health
Institute, University of South Florida, Tel. 813-974-6409; Fax. 974-6257 Email:
clark@fmhi.usf.edu
c.
Other resources

Advice of Consensus Panels and Other Experts: Davis13 reviewed the state of
transition research and policy, including results of two ad hoc consensus panels
which made recommendations prior to 2003. These groups were still struggling with
issues of leadership and funding and did not address service provision. Clark cites a
wide range of articles as representing “professional consensus” in his “TIP System
Guidelines and Practice Elements with Associated Empirical Research Findings or
Professional Consensus,” available from the TIP website. These are not, however,
consensus panel findings but consist of conceptual papers and literature reviews of
specific elements related to TIP guidelines. The Division on Career Development and
Transition of the Council for Exceptional Children has published a series of “position
statements” on transition.14 As noted above, there is a textbook available on transition
services for young persons with disabilities.15

An edited book about transition-age youth issues and strategies for serving them has been
published by the developers;16 available for $29.95 at: http://www.brookespublishing.com/

An edited book provides detailed instructions and forms/instruments for many transition services and
functions from the standpoint of schools. Bullis, M., & Fredericks, H. D. (Eds.). (2002). Vocational and
transition services for adolescents with emotional and behavioral disorders: Strategies and best practice.
Champaign, IL: Research Press.

There is a computerized outcome tracking system (Transition to Adulthood Program Information
System [TAPIS] Progress Tracker) that is currently being programmed into a software system for
dissemination. The Transition to Adulthood Assessment Protocol (TAAP) is an integrated
management information system developed for youth in the PYT program.

The NCYT Team maintains two websites that contain many other resources:
<http://tip.fmhi.usf.edu> and <http://ncyt.fmhi.usf.edu>. The latter is the National Center on
Youth Transition for Behavioral Health website.
California Institute for Mental Health
Page 9
Endnotes
1 Description is from the developers of the model. The primary developer is Hewitt B. (Rusty) Clark. He has worked with and published with a number of other researchers. The
current University of South Florida team is described at: http://tip.fmhi.usf.edu/tip.cfm?page_ID=14
2 Information is drawn from: Karpur, A., Clark, H. B., Caproni, P., & Sterner, H. (2005). Transition to adult roles for students with emotional/behavioral disturbances: A follow-up
study of student exiters from Steps-to-Success. Career Development for Exceptional Individuals, 28(1), 36-46; and Carroccio, D. F., Whitfield, D., Clark, H. B., & Karpur. (2003).
Transition to Independence Process (TIP): System Development & Research Merged Data Analysis (MDA) Project: Parts I through V. Retrieved November 14, 2006.
tip.fmhi.usf.edu/files/report_5_MDA_STS_Follow-up_web_02_05_04.pdf
3 Clark, H. B., Pschorr, O., Wells, P., Curtis, M., & Tighe, T. (2004). Transition into community roles for young people with emotional/behavioral difficulties: Collaborative
systems and program outcomes. In D. Cheney (Ed.), Transition issues and strategies for youth and young adults with emotional and/or behavioral difficulties to facilitate
movement in to
community life : Council for Exceptional Children.
4 Lead evaluator is Nancy Koroloff: 503.725.4040, koroloffn@pdx.edu. Presentations are available at: http://www.rri.pdx.edu/CCTransitions/CCTranreports.htm
5 Bullis, M., Moran, T., Benz, M., Todis, B., & Johnson, M. (2002). Description and evaluation of the Aries Project: Achieving rehabilitation, individualized education, and
employment success for adolescents with emotional disturbance. Career Development for Exceptional Individuals, 25(1), 41-58.
6 Cheney, D., Hagner, D., Malloy, J., Cormier, G., & Bernstein, S. (1998). Transitional services for youth and young adults with emotional disturbance: Description and initial
results of Project RENEW. Career Development for Exceptional Individuals, 21(1); and Hagner, D., Cheney, D., & Malloy, J. (1999). Career-Related Outcomes of a Model
Transition Demonstration for Young Adults With Emotional Disturbance. Rehabilitation Counseling Bulletin, 42(3).
7 This information is from Bullis, M., Tehan, C. J., & Clark, H. B. (2000). Teaching and developing improved community life competencies. In H. B. Clark & M. Davis (Eds.),
Transition to Adulthood. Baltimore: Paul H. Brookes Publishing Co. A separate article presents data on the first three years of the project, with fewer participants. The article
contains much more information about the program design. Bullis, M. (1994). Description and evaluation of the Job Designs program for adolescents with emotional or behavioral
disorders. Behavioral Disorders, 19, 254-268.
8 Davis, M. (2003). Addressing the needs of youth in transition to adulthood. Administration and Policy in Mental Health, 30(6), 495-509.
9 Collins, M. E. (2001). Transition to adulthood for vulnerable youths: A review of research and implications for policy. Social Service Review, 75(2), 271-291.
10 Marsenich, L. (2005). A Roadmap to Mental Health Services for Transition Age Young Women: A Research Review Sacramento: California Women’s Mental Health Policy
Council in conjunction with the California Institute for Mental Health.
11 Hyde, P. S., Falls, K., Morris, J., John A., & Schoenwald, S. K. (2003). Turning Knowledge into Practice: A Manual for Behavioral Health Administrators and Practitioners
About Understanding and Implementing Evidence-Based Practices. Boston: Technical Assistance Collaborative, Inc., for The American College of Mental Health Administration.
12 Clark, H. B. (2004). TIP System Development and Operations Manual Tampa, Department of Child and Family Studies, Louis de la Parte Florida Mental Health Institute,
University of South Florida. Downloadable from the TIP website: http://tip.fmhi.usf.edu
13 Davis, M. (2003). Addressing the needs of youth in transition to adulthood. Administration and Policy in Mental Health, 30(6), 495-509.
14 See for example: Halpern, A. S. (1994). The transition of youth with disabilities to adult life: A position statement of the Division on Career Development and Transition of the
Council for Exceptional Children. Career Development for Exceptional Individuals, 17(2), 115-124;
available:http://eric.ed.gov/ERICWebPortal/Home.portal?_nfpb=true&_pageLabel=RecordDetails&ERICExtSearch_SearchValue_0=ED299757&ERICExtSearch_SearchType_0
=eric_accno&objectId=0900000b80044b36
15 Sitlington, P. L., Clark, G., & Kolstoe, O. (2000). Transition Education and Services for Adolescents with Disabilities (Third ed.). Boston: Allyn and Bacon.
16 Clark, H. B., & Davis, M. (Eds.). (2000). Transition to Adulthood: A resource for assisting young people with emotional or behavioral difficulties. Baltimore: Paul H. Brookes.